“Blood work was supposed to be the last step in Isela’s application for life insurance. But when she arrived at the lab, her appointment had been cancelled.

“That was my first warning,” Isela said. She contacted her insurance agent and was told her application was denied because something on her medication list indicated that Isela uses drugs. Isela, who works in an addiction treatment program at Boston Medical Center (BMC), scanned her med list. It showed a prescription for the opioid-reversal drug naloxone, brand name Narcan.

That’s a message public health leaders aim to spread far and wide. “BE PREPARED. GET NALOXONE. SAVE A LIFE,” summarized an advisory from the U.S. surgeon general in April.

But life insurers consider the use of prescription drugs when reviewing policy applicants. And it can be difficult to tell the difference between someone who carries naloxone to save others and someone who carries naloxone because they are at risk for an overdose.”

“The United States is in the midst of an opioid crisis. Every day, over 100 people die from opioid overdoses, according to the US Centers for Disease Control and Prevention. But what if we could know about overdoses before they happen?

Scientists in California have opened the possibility of having such preemptive knowledge by creating a model that uses Google searches to predict overdoses from heroin. Their research, published in the journal Drug and Alcohol Dependence in September and reported on this week in Scientific American, shows that Google searches for certain drugs, including slang terms, can be used to explain heroin-related visits to hospitals.”

“Deaths from drug overdose in the United States increased by 54% from 2011 to 2016 — with opioids, benzodiazepines (benzos), and stimulants the most commonly used drug classes involved, a new report released today by the Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS), shows.

The report notes that there were 41,340 drug overdose deaths in 2011 vs 63,632 such deaths in 2016.

Although the opioid oxycodone was the most cited drug in overdose death records in 2011, heroin took the top spot from 2012 to 2015.

The story around fentanyl may be even more troubling. The rate of overdose deaths involving it or one of its analogs doubled each year from 2013 through 2016, when it finally took the lead in becoming the most mentioned drug. In 2016, 29% of all overdose deaths involved fentanyl (n = 18,335).”

“A drug company is offering a significantly cheaper version of its life-saving opioid overdose treatment after a Senate investigation found that it spiked the price of its drug.

A report from the Senate’s Permanent Subcommittee on Investigations last month found that the company, Kaléo, hiked the price of its drug Evzio to $4,100 for two injectors, raising the price by more than 600 percent between 2014 and 2017.

After this scrutiny, the company on Wednesday announced that it will offer a cheaper generic version of the drug for $178 for two injections.”

“An authorized generic for kaléo’s naloxone HCl injection (Evzio®) will be available midyear in 2019, and will come with a list price of $178 per carton, each containing 2 auto-injectors. Offered through kaléo subsidiary IJ Therapeutics, the new authorized generic is the same formulation and design as the branded drug, but will have a different label.

Although Evzio is currently available for $0 out-of-pocket to eligible patients with commercial insurance, the lower list price of the authorized generic will offer a more affordable and cost-effective solution for Medicare Part D patients and plans.”

“Providers aren’t using telemedicine enough for substance use disorder treatment, and researchers say the resource is a “missed opportunity” when drug overdose deaths continue to climb and access to care remains limited.

Telemedicine visits for substance use disorder jumped from 97 in 2010 to nearly 2,000 by 2017, according to an analysis published Monday in Health Affairs. But substance use disorder represented only 1% of all telemedicine visits in 2017, and they made up 0.1% of all substance use disorder treatment visits.

Telemedicine growth in substance use treatment has been stymied by federal regulations that require prescribers of medication-assisted treatments like buprenorphine to see patients in-person first. That requirement can make it difficult for patients in areas with few or no clinicians certified to prescribe MAT to receive treatment. There is an exception that allows local clinicians to prescribe buprenorphine if they’re supervised by another provider via telemedicine.”

“The United States has more than double the rate of premature overdose deaths of at least 12 other countries, according to a new study.

The research, published Monday in the Annals of Internal Medicine, says that there were an estimated 63,632 drug overdose deaths in 2016 in the US.

“The U.S. has the highest death rate due to drug overdoses for both men and women (35 deaths in 100,000 men and 20 deaths in 100,000 women) in 2015, more than double those of any other country in our study,” Yingxi Chen, one of the researchers and a postdoctoral fellow at the National Institutes of Health’s National Cancer Institute, wrote in an email.

Mexico had the lowest rates: 1 death per 100,000 men and 0.2 deaths per 100,000 women.”

“The Food and Drug Administration is considering requiring doctors to prescribe an overdose reversal drug with prescription painkillers such as OxyCodone, Commissioner Scott Gottlieb announced Tuesday.

The overdose antidote, known as naloxone, can save the lives of people who’ve suffered overdoses. The FDA may require the drug to be prescribed every time a patient receives an opioid to treat pain, or only if they receive a particularly high dose.

The move has been pushed by the makers of Narcan, a nasal spray version of the drug that people can use at home. The drug also comes in the form of an auto-injector known as Evzio, another form that people can use on someone who has overdosed even if they’re not in the medical field.”

“The U.S. is “beginning to turn the tide” on the opioid epidemic, HHS Secretary Alex Azar said Tuesday, pointing to new federal data showing a slight dip in overdose deaths last year.

Preliminary CDC data released last week shows drug overdose deaths, which spiked in 2017, dropped 2.8 percent toward the end of last year and the beginning of 2018.

“The seemingly relentless trend of rising overdose deaths seems to be finally bending in the right direction,” Azar said in prepared remarks at the Milken Institute’s health care conference in Washington, D.C.

CDC Director Robert Redfield cautioned that his agency’s numbers are preliminary but said they are encouraging.”

Under federal law, newly enrolled methadone patients must attend a methadone program six days a week, so caregivers can watch as patients are dosed.

But here’s the problem: Because many new methadone patients don’t have an opioid treatment program (OTP) nearby, this need for daily attendance markedly affects adherence. In fact, 20% to 50% of patients report poor or partial adherence during the most critical time of treatment—the first month, when patients face the highest risk of death.

That’s the subject of a study published this month in Journal of Substance Abuse Treatment.

The study’s authors, most of whom are affiliated with Washington State University, assessed the relationship between spatial access to the only state-funded OTP in Spokane County, Washington, and adherence to treatment during the crucial first month.

Authors’ Hypothesis—Treatment adherence is lower in new patients who live farther from the OTP.

Findings

The 892 patients received their first month’s treatment sometime between February 2015 and December 2017.

Effects of Distance

In the crucial first month of treatment:

Patients living between 5 and 10 miles from the OTP were just as likely to miss doses as those living less than 5 miles away

Patients living more than 10 miles away were more likely to miss methadone doses than patients living within 5 miles

Patients living more than 10 miles away were younger, on average, than those closer; these younger, farther patients were considered possibly at higher risk of not adhering to treatment—and thus at higher risk of death

Other Considerations

Time in Therapy

In the first three months, patients were required to complete 12 sessions of cognitive or behavioral therapy. After three months, take-home doses could be considered for those with good adherence. Also, mandatory attendance for therapy dropped to once monthly.

Age

Median age was 34 years. The older the patient, the less the likelihood of missed doses. For every year of greater patient age, missed doses dropped 2%.

Distance

The authors commented that previous studies suggest that lower income, higher medication costs, and transportation barriers may influence nonadherence, affecting Medicaid patients, such as those in this study.

Day of the Week

Patients were most likely to miss Saturday and Sunday doses. The staff provided Sunday take-home doses only until 2 PM Saturday.

Conclusions

The research team found that during the first month of treatment, “significant positive associations” existed between the number of doses patients missed and the distance patients traveled to the OTP.

The authors stressed the importance of regular attendance, and the need to “improve the spatial availability of OTPs” for patients scattered throughout the area.

Bottom Line

Methadone treatment is known to reduce or eliminate drug use, risky sexual behavior, criminal behavior, and deaths. But many OTP patients lose these benefits early, because no OTP is nearby. Evidence points to the first month as being key.

COMMENT: The authors have provided valuable data showing that the legal need to observe patients’ daily dosing may affect compliance. They’ve also raised important issues for further investigation.

In the meantime, laws have been passed limiting the availability of prescription opioids, and other investigators have suggested different approaches to the opioid problem, described below.

Rosenblum et al. Writing in The Journal of Environmental and Public Health, these authors recommended flexible take-home policies, mobile methadone maintenance services, and methadone medical maintenance—methadone provided by an office-based physician, or a pharmacy. Good ideas, all awaiting implementation. But the awaiting continues: The study was published seven years ago, the opioid crisis continues to surge, and the obstacles remain.

Saitz and Daaleman. Early this year an article in The Annals of Family Medicine urged making methadone treatment part of primary care. The authors said it would be impossible for the country to adequately respond to the current epidemic “without addressing it in primary care and there is no question that the time to do it is now.”

Samet et al. An article in the July issue of New England Journal of Medicine also called for primary care availability—specifically, by asking Congress to update laws. Regulating methadone prescribing in primary care would reduce barriers, the authors said, and would “extend the benefits of a proven, effective medication to people throughout the country.”

Given the variety of approaches to the opioid crisis—restricting opioid prescriptions, constructing more OTPs, allowing primary-care prescribing—what’s the best way to proceed?

The Stanford Approach: Modeling Tools Provide Assessments

A team from Stanford University used sophisticated modeling tools to assess the benefits and harms of various responses to the opioid crisis. They found that policies that expand addiction treatment or mitigate addiction’s harmful effects, such as overdose and infection, are “immediately and uniformly beneficial.” And they lack negative consequences, such as increasing heroin-related deaths. The team published its findings this month in the online edition of The American Journal of Public Health.

As for policies that decrease the supply of prescription opioids—they can reduce prescription-related deaths, but could also increase heroin-related deaths, as some people seek heroin as a substitute for prescription opioids. It’s possible, the team believes, that eventually “some such policies may avert enough new addiction to outweigh the harms.”

What, then, is the best policy? It seems there’s no perfect answer. The Stanford team suggested “a portfolio of interventions,” but these would include reducing the prescription opioid supply, probably increasing heroin use temporarily. It would also deprive some patients with chronic pain of a medication they legitimately need.

Opening more OTPs, as the Washington State team recommends, wouldn’t have that disadvantage, and the data indicate it would optimize treatment outcomes.